Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care with a focus on medically complex/medically fragile cases. Assists in coordinating services with federal and state programs, and other community services to the member. Promotes effective healthcare utilization, monitors health care resources and assumes a leadership role within the Interdisciplinary Care Team (ICT) to achieve optimal clinical and resource outcomes. Works with the Manager of Service Coordination to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member. Receives and reviews authorizations for services from providers and members via phone, fax or written request. May be required to perform nursing HCBS Skills Check list for providers under the Self-Direction program. Provides clinical guidance, expertise and training to non-RN Service CoordinatorsEssential Functions:
Conducts face-to-face Health and Functional Assessments (HFA) for all members on an annual or more frequent basis (as applicable).
Conducts a functional level of care assessment using DHS Form 1147 on selected members annually.
Develops a Care Plan for each member, in conjunction with the PCP and member, based upon the HFA.
Interacts with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status and to assess the options for care including use of benefits and community resources to update the Care Plan.
Coordinates community resources with emphasis on the development of natural support system and coordinates benefits, regulations, laws and public entitlement programs.
Maintains HIPAA standards and confidentiality of protected health information; and reports critical incidents and information regarding quality of care issues.
Utilizes compiled data received from member electronic record to assure that the services being provided meet the member's needs.
Facilitates member and provider authorization and access to services.
Seeks to resolve any concerns about care delivery or providers.
Monitors member self-direction delivery process.
Assists QI department with monitoring of progress with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements.
Refers members with suspected severe emotional, behavioral and/or mental illness for evaluation;
Manages a caseload that does not exceed 1880 hours annually, based on case intensity and acuity.
Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintains accurate records of service coordination activities in the system using clinical guidelines.
Ensures compliance with all state and federal regulations and guidelines.
Provides counseling on options regarding institutional placement and HCBS alternatives.
Assists members in transitioning to and from nursing facilities/residential facilities.
Trains and/or refers to an agency provider for training Self-Direct HCBS PA 2 providers; Assures the competency of each provider using the 'Ohana Skills Check List.
Refers RN delegated skills providers to an agency provider for training.
Performs other duties as assigned.
Education: Diploma, Associate's or Bachelor's Degree in Nursing.Experience:
Minimum of 2 years of relevant healthcare experience with client care coordination responsibilities (preferably in long-term care). 3-5 years desired.
Experience working as a Case Manager desired; Certified Case Manager (CCM) preferred.
Experience in working with special populations, such as HIV/AIDS, developmental disabilities, medically fragile children, geriatrics, persons with neurotrauma, and younger adults with physical disabilities.
Managed care experience preferred.
Licensure in the state of Hawaii as a registered nurse (RN) required.
Special Skills (e.g. 2nd language):
Advanced ability to communicate on any level required to meet the demands of the position.
Ability to create, review and interpret treatment plans.
Bi-lingual in English and any of the following languages preferred: Ilocano, Tagalog, Mandarin Chinese, or Korean a plus.
Knowledge of Microsoft Office including Excel, Word and Outlook.
Knowledge of data entry, documentation and report generation in any clinical system a plus.
Other Position Requirements:
Uses discretion and independent judgment when applying criteria in determining case management and service needs, and other matters of clinical significance.
Performs complex administrative tasks closely guided by policy and past clinical practice.
Makes decisions within the scope of the job, consistent with Plan/department policy and procedure.
Knowledge of current professional case management practices, standards, responsibilities and procedure.
Knowledge of the problems and needs of the targeted population, including social, health, and psychosocial factors affecting optimal functioning of members and their support systems.
Knowledge of client's rights, state and federal laws, and regulations, such as those relating to health services, confidentiality, and consent issues for the targeted population.
Ability to communicate effectively in person and by phone, travel to member's location of residence and uses a laptop computer to complete the HFA, initial care plan and documentation.
Ability to work independently, handle multiple assignments and prioritize workload.
Ability to seek help in managing workload, when appropriate.
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.